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Kaiser Clerks Paid More for Helping Less
Health care: Bonuses were given for limiting members' calls and
doctors'
appointments. HMO defends program but has dropped it.
By CHARLES ORNSTEIN
Times Staff Writer

May 17 2002

Kaiser Permanente, the state's largest HMO, until
recently had awarded
financial bonuses to call center clerks who spent the least
amount of time on the phone with each patient and limited the number
of doctors' appointments, internal documents show.

From January 2000 until last December, telephone
service
representatives
at Kaiser's three call centers in Northern California could
earn a bonus of up to 10% of their salary if they arranged appointments
for 15% to 35% of callers and if they spent less than an average
of three minutes, 45 seconds on the phone per patient.

Moreover, a recent Kaiser-commissioned survey of
505
registered nurses
at those centers found they had "a serious concern" that callers
were being forced to wait too long for doctors' appointments. The call
centers, which handle appointments and inquiries for Kaiser's
3 million members in Northern California, are in Sacramento, Vallejo
and San Jose.

Nurses "feel unable to help patients and said they
spend
a lot of time
dealing with frustrated members when they are not able to schedule
appointments," said the Terranova Consulting Group report, obtained
by The Times.

Nurses did not participate in the clerks' bonus
program.

Kaiser spokesman Jim Anderson dismissed
suggestions that
the bonuses
were intended to make it more difficult for patients to access care.
Rather, he said, they were intended to reward good service and were
based on the call centers' past performance.

"This was a pilot program, and it was discontinued
because it was determined
that it wasn't working" and didn't improve service to members,
he said.

"It's always difficult to balance the amount of
time
spent with an individual
caller versus the amount of time that the next person has to wait to
talk to someone," Anderson said. "We'll always err on the side of
helping
the person who is on the phone who needs our assistance."

Since the nurses survey, Anderson said, Kaiser has
made
improvements
in scheduling, training and appointment availability in Northern
California.

The California Nurses Assn., the union
representing
Kaiser's registered
nurses, contends that the main problem with the call centers is that
unlicensed telephone clerks field patient calls and make decisions
about when to schedule appointments or refer a caller to a medical
advice
nurse.

That amounts to evaluating a patient's medical
condition, a task restricted
to licensed medical personnel by state law, the union contends.

State HMO regulators said Thursday that they are
investigating that
complaint.

"If we weren't concerned, we wouldn't be looking
at it,"
said Daniel
Zingale, director of the California Department of Managed Health Care.

Although Zingale would not discuss the inquiry in
detail, he said his
office has the power to order Kaiser to change its call center
policies.

Kaiser knows of no state inquiry, Anderson said,
adding
that no regulators
have visited Kaiser facilities regarding these matters.
"If there are questions, we would be happy to work with whoever is
raising them and help them resolve them," he said.

One of Kaiser's own physicians found problems at
the
Vallejo call center.
Dr. Harvey Kayman, a doctor at the pediatric call center from
December 1999 until April 2000, wrote in a report the month he left
that the center needed a "complete revision of the mission, goals and
objectives ... so that it no longer functions as a barrier, but an
agent of communication."

Kayman said pediatric medical providers sent him
messages reflecting
their "distrust, anger, disappointment and pessimism about the call
center."

Patients have complained about "the impersonal
nature of
the service
they receive" and believe that the call center "puts a barrier between
them and their clinical providers," he wrote.

Anderson said Kayman's report was unsolicited.
But,
"interestingly enough,
many of the things listed in his report were already on the
drawing board for changes at the call center," he said.

The incentive plan for the telephone clerks was
unveiled
in January
2000 in company memos. The incentives were a joint pilot program
between Kaiser and Service Employees International Union Local 250,
which represents the telephone clerks.

To qualify for a bonus, employees had to meet
three of
four criteria,
according to one memo:

Handle regular calls in less than three minutes
and 45
seconds and foreign
language calls in under eight minutes 30 seconds.

Schedule or request appointments in 15% to 35% of
cases.

Transfer fewer than 50% of calls--60% on nights
and
weekends--to advice
nurses for additional help.

Spend an average of 75% or more of the workday
answering
calls.

Bonuses, from 2% to 10% of a worker's salary, were
awarded if staff
members met or exceeded the targets, the document says.
Other factors to be considered were attendance, tardiness and customer
service. Each person could earn up to $625 in bonuses every quarter.

An internal document, titled "Talking Points for
Managers," said the
bonuses are a way to "reward and encourage performance
improvements."

"Kaiser Permanente is making a financial
commitment to
its employees
for the purpose of improving our phone service to members,"
the document said.

Dr. Linda Peeno, a former health plan medical
director
who now testifies
against HMOs in malpractice suits, said the Kaiser incentive
program was "egregious."

"It just virtually ensures that you're not going
to get
appropriate
evaluation, and you're certainly not going to get access to anyone who
would be able to evaluate you appropriately," said Peeno, whose own
experiences in HMOs is the subject of the upcoming Showtime movie
"Damaged Care."

"It's a recipe for not just minimal care, but no
care."

In the recent survey, Kaiser's call-center nurses
reported feeling pressure
to spend little time with each patient.

"The nurses are being forced to quickly deal with
these
people, write
it up and move on to the next one or else they're disciplined,"
said Morton Newman, one of the union's labor representatives.

Nurses get regular reports outlining their average
handling time, and
that criterion is factored into their annual evaluation, he said.

"There's tremendous pressure on the nurses to cut
off
the calls, which
is a conflict with their license," Newman said.

Anderson said there is no limit to the amount of
time
nurses can spend
with callers. The Kaiser documents, obtained by The Times,
come nine months after a top Kaiser official acknowledged past delays
in meeting patients' demands. He said those problems were rectified.

According to minutes of a meeting last year, the
chief
executive of
Kaiser's Northern California physician group described how in the past
"we chose not to provide our patients with what they desired." Kaiser
documents suggested that his was done to save money and "control
demand."

That strategy proved counterproductive because
patients
persisted until
they got past the telephonic triage system, the doctor said.
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